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Healthcare Safety: How will your next patient be injured?

Healthcare Safety: How will your next patient be injured?. Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital. Why Safety and Why Now?. Why Safety and Why Now?. Your patients deserve it Insurance payers demand it. Protect your Reputation and Reimbursement.

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Healthcare Safety: How will your next patient be injured?

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  1. HealthcareSafety:How will your next patient be injured? Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital

  2. Why Safety and Why Now?

  3. Why Safety and Why Now? Your patients deserve it Insurance payers demand it

  4. Protect your Reputation and Reimbursement • CMS monitors and reports outcome • Patients have access to National Database • APSF provides advisories regarding equipment, techniques and drugs. • Most important: Focus on safety because you owe it to your patients • Eliminate “never”events • Reduce high frequency risks. • CLABSI • VAP

  5. Government will not pay when: • A foreign object is retained within a patient´s body after surgery. • The development of an air embolism within a patient´s body. • A patient blood transfusion with incompatible blood. • A patient´s development of stage III or stage IV pressure ulcers. • Patient injuries resulting from accidental falls and other trauma

  6. Government will not pay when: • A patient has of poor glycemiccontrol • A patient develops a catheter-associated urinary tract infection. • A patient develops a vascular catheter-associated infection. • A patient develops a surgical site infection following: • A coronary artery bypass graft - mediastinitis; • Bariatric surgery, • Orthopedic procedures, including, but not limited to, such procedures performed on the spine, neck, shoulder and elbow. • A patient develops deep vein thrombosis

  7. Direct Benefits • Increased Patient Satisfaction • Staff engagement • Collaborative teambuilding across lines • Lean Sigma work flow gains • Financial rewards

  8. How Do Hospitals Compare?

  9. CUSP for Patient Safety Continuous Unit Based Safety Program

  10. Why the CUSP FORMAT? • Improve safety culture and learn from mistakes • Can be implemented throughout organization • Values the wisdom of front line staff • Linked with improvement in clinical outcomes • Empowers staff to be actively involved • Reduces barriers between staff and senior leadership. Armstrong Institute for Patient Safety

  11. Building Your Safety Program • Build a CUSP • Must include ALL stakeholders • All CUSP members have an equal say • Engage Hospital leadership • Seek type 2 solutions • Make a long term commitment Armstrong Institute for Patient Safety

  12. The Process: • Assemble a CUSP Team • Assess your Safety Culture • Learn/Teach the Science of Safety • Identify Defects • Form Executive Partnerships • Learn from Defects • Develop Tools for Improvement Armstrong Institute for Patient Safety

  13. CUSP Team Members: • Transdisciplinary and collaborative • Team Leader • Surgeon Champion • Anesthesia Champion • Nursing Champion • Executive Champion • Frontline staff (PACU, ICU, OR, Surgical floors Armstrong Institute for Patient Safety

  14. Safety Culture • Formal Survey (AHRQ) • HSOPS – Hospital survey of patient safety • NPSF has excellent PDF download • http://www.npsf.org/wp-content/uploads/2011/10/PLS_1102_SS.pdf • Local Survey • How will our next patient be injured? • What can we do to prevent it?

  15. Culture versus Outcome • The Health foundation, November 2011 • As Safety Culture increased; • Readmission rates decreased • Length of ICU stay decreased • Complications decreased • Medication errors decreased • Adverse events decreased • Patient satisfaction increased

  16. Science of Safety • Every system is perfectly designed to achieve the results it gets • Understand the principles of safe design • Standardize, checklists, learn from mistakes • Recognize that principles apply to technical and team work • Teams make wise decisions when there is diverse and independent input Armstrong Institute for Patient Safety

  17. Identify Defects • How will the next patient be injured? • What can be done to prevent this harm? • Surgical site infection? • Production pressure? • Communication? • Prioritize your effort • Severity of harm • Frequency of harm

  18. Form Executive Partnerships • Executive member is essential • Stimulates discussion • Helps prioritize efforts • Can lobby C-Level for policy change • Access to resources • Helps resolve inter-department issues • Must be committed and available for safety rounds

  19. Learn From Defects • What Happened? • Why did it happen? • What did you do to reduce the risk? • How do you know the risk was reduced?

  20. Form Executive Partnerships • Executive member is essential • Stimulates discussion • Helps prioritize efforts • Can lobby C-Level for policy change • Access to resources • Helps resolve inter-department issues • Must be committed and available for safety rounds

  21. Develop Tools to Improve • CUSP for Safe Surgery website • Technical tools • Briefing/Debriefing tools • Checklists • Adaptive Tools • Perioperative daily huddle • Shadowing other professionals.

  22. CUSP is an ongoing process, and is never truly finished. Armstrong Institute for Patient Safety

  23. So…How will your next patient be harmed? What will you do to prevent it?

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